Inspection·October 5, 2023

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some .Outcomes of Physical Assessment: Positive findings reported on the resident/patient evaluation for this change in condition were: Mental Status Evaluation: Altered level of consciousness (hyperalert, drowsy but easily roused, difficult to arouse) Increased confusion (e.g. disorientation); Functional Status Evaluation: General Weakness .Nursing observations, evaluation, and recommendations are: Resident appears to have decreased level of consciousness with weakness accompanied with decreased O2 saturation .Family is at bedside and have been notified regarding change of condition. Doctor (Dr-name of doctor ' s PA-Physician ' s Assistant) is aware Resident has been transferred to (name of hospital) at 7:56 pm. On October 2, 2023, at 2:53 p.m., the Director of Staff Development (DSD) was interviewed regarding Resident 1 ' s Depakote ER and Depakote DR medication. The DSD stated ER was extended release and DR was delayed release. The DSD stated they belong to same family of medication but different and separate medication. The DSD stated the medication should have been reviewed with MD. The DSD stated that there could be a potential adverse reaction for new medication like changes in cognitive status or changes in condition like lethargy and changes in VS (vital signs). The DSD stated to prevent it from happening again, the licensed nurses had to verify and double check for any previous orders to avoid duplication of medication orders. On October 2, 2023, at 3:10 p.m., a concurrent record review and interview was conducted with Licensed Vocational Nurse (LVN) 2. LVN 2 verified her initials made on July 1, 2023, Medication Administration Record (MAR), signifying she had administered Depakote ER 500 mg and Depakote DR 500 mg at bedtime. LVN 2 stated it was an unnecessary medication. LVN 2 stated, to prevent duplication, one had to pay attention to previous orders to prevent error. On October 2, 2023, at 3:24 p.m., a concurrent record review and interview was conducted with LVN 3. LVN 3 verified her initials made on June 28, 2023, July 3, 4, 9, and 10, 2023 MAR, signifying she had administered Depakote ER 500 mg and Depakote DR 500 mg at bedtime. LVN 3 stated both Depakote ER and DR belong to same classification of medication. LVN 3 stated to prevent it from happening in the future, make sure to check the previous order before entering new ones to avoid duplication. LVN 3 stated duplication can cause over-medication and patient may get lethargic. LVN 3 stated she heard the family was saying the resident was more sleepy and not as active, and it caused him to be lethargic. LVN 3 stated it could cause changes with mentation and residents may not be able to protect themselves from a potential fall. On October 2, 2023, at 4:12 p.m., the Director of Nursing (DON) and Administrator (ADM) were interviewed regarding Resident 1 ' s Depakote ER 500 mg at bedtime and Depakote DR 500 mg at bedtime medication duplication of orders, and interviews conducted with nurses verifying they have administered both medications on June 28, 2023, through July 11, 2023. The order produced unnecessary medication to address behavior management. A review of the policy and procedure titled, Medication- Administration, dated January 1, 2012, indicated, .To ensure the accurate administration of medications for residents in the facility .If the Attending Physician increases or changes a medication order, this is an automatic stop or discontinue order for original order .Nursing staff will keep in mind the seven 'rights' of medication when administering medication . A review of the facility policy titled, Behavior/Psychoactive Drug Management, dated November 2018, indicated, Policy: It is the policy of this Facility to provide person-centered, comprehensive and interdisciplinary care that reflects best practice standards for meeting health, safety, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055042 If continuation sheet Page 2 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055042 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alta Vista Healthcare & Wellness Centre 9020 Garfield Street Riverside, CA 92503 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm psychosocial, behavioral, and environmental needs of residents to obtain or maintain the highest physical, mental, and psychosocial well-being .G. Appropriate dosage must be prescribed .The treatment should be at the lowest possible dose to improve the target symptoms being monitored . Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055042 If continuation sheet Page 3 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055042 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alta Vista Healthcare & Wellness Centre 9020 Garfield Street Riverside, CA 92503 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to prevent administration of unnecessary medication to one of five sampled residents (Resident 1), when Resident 1 was administered with Depakote (medication used to treat seizures and bipolar disorder)DR (delayed released -delayed release of drugs in the body) and Depakote ER (extended released-drug is released slowly to provide a prolonged therapeutic effect), at bedtime without adequate indication for duplicated use. Residents Affected - Few The facility failure had resulted in Resident 1 receiving unnecessary medication for 11 days which could potentially cause drug adverse reaction, complications, and unnecessary hospitalization. Findings: On August 7, 2023, at 10:25 a.m., an unannounced visit was conducted to investigate quality care issues. On August 7, 2023, Resident 1 ' s record was reviewed. The Physician ' s Order by Licensed Vocational Nurse (LVN) 1, dated 06/27/2023, at 4:54 p.m., indicated an order for, Depakote ER Oral Tablet Extended Release 24 Hour 500 MG (Divalproex Sodium) Give 1 tablet by mouth at bedtime for SCHIZOAFFECTIVE DISORDER (D/O) BIPOLAR TYPE (mental illness that can affect thoughts, mood, and behavior) MANIFESTED BY (M/B) MOOD SWINGS INFORMED CONSENT (I/C) OBTAINED BY MEDICAL DOCTOR (M/D). The resident ' s record further indicated another order from Registered Nurse (RN) 1, on June 28, 2023, at 13:27 p.m., for, Depakote Oral Tablet Delayed Release (DR) 500 MG (Divalproex Sodium) Give 1 tablet by mouth at bedtime for M/B MOOD SWINGS IC OBTAINED. On October 2, 2023, at 2:35 p.m., RN 1 was interviewed on Depakote ER and Depakote DR orders made on June 27, 2023, and June 28, 2023, respectively. RN 1 stated ER stands for extended release and DR was for delayed release. RN 1 stated that if there had been a previous order already for Depakote ER, she should have clarified with the MD first before ordering Depakote DR. RN 1 stated she did not see the order for Depakote ER. RN 1 stated it should have been discontinued before ordering the Depakote DR to avoid duplication of orders. RN 1 indicated both medications belong to the same drug classification. A review of June 2023 and July 2023, MAR (Medication Administration Record) was conducted with RN 1. The MAR indicated both Depakote ER and DR were administered at 9 p.m., on June 28, 2023, through July 7, 2023. The resident's Depakote DR was discontinued on July 11, 2023, when the resident ' s (family member) visited and found the resident swollen and having difficulty breathing. A review of Resident 1's record documented on July 11, 2023, at 7:52 p.m., titled, Change in Condition (CIC), indicated, Situation: The Change In Condition/s report and mood stabilizer on this CIC Evaluation are/were: Altered mental status Other change in condition Tired, Weak, Confused, or Drowsy .Outcomes of Physical Assessment: Positive findings reported on the resident/patient evaluation for this change in condition were: Mental Status Evaluation: Altered level of consciousness (hyperalert, drowsy but easily roused, difficult to arouse) Increased confusion (e.g. disorientation); Functional Status Evaluation: General Weakness .Nursing observations, evaluation, and recommendations are: Resident appears to have decreased level of consciousness with weakness accompanied with decreased O2 saturation .Family is at bedside and have been notified regarding change of condition. Doctor (Dr-name of doctor ' s PA-Physician ' s Assistant) is aware Resident has been transferred to (name of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055042 If continuation sheet Page 4 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055042 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alta Vista Healthcare & Wellness Centre 9020 Garfield Street Riverside, CA 92503 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 hospital) at 7:56 pm. Level of Harm - Minimal harm or potential for actual harm On October 2, 2023, at 2:53 p.m., the Director of Staff Development (DSD) was interviewed regarding Resident 1 ' s Depakote ER and Depakote DR medication. The DSD stated ER was extended release and DR was delayed release. The DSD stated they belong to same family of medication but different and separate medication. The DSD stated the medication should have been reviewed with MD. The DSD stated that there could be a potential adverse reaction for new medication like changes in cognitive status or changes in condition like lethargy and changes in VS (vital signs). The DSD stated to prevent it from happening again, the licensed nurses had to verify and double check for any previous orders to avoid duplication of medication orders. Residents Affected - Few On October 2, 2023, at 3:10 p.m., a concurrent record review and interview was conducted with Licensed Vocational Nurse (LVN) 2. LVN 2 verified her initials made on July 1, 2023, Medication Administration Record (MAR), signifying she had administered Depakote ER 500 mg and Depakote DR 500 mg at bedtime. LVN 2 stated it was an unnecessary medication. LVN 2 stated, to prevent duplication, one had to pay attention to previous orders to prevent error. On October 2, 2023, at 3:24 p.m., a concurrent record review and interview was conducted with LVN 3. LVN 3 verified her initials made on June 28, 2023, July 3, 4, 9, and 10, 2023 MAR, signifying she had administered Depakote ER 500 mg and Depakote DR 500 mg at bedtime. LVN 3 stated both Depakote ER and DR belong to same classification of medication. LVN 3 stated to prevent it from happening in the future, make sure to check the previous order before entering new ones to avoid duplication. LVN 3 stated duplication can cause over-medication and patient may get lethargic. LVN 3 stated she heard the family was saying the resident was more sleepy and not as active, and it caused him to be lethargic. LVN 3 stated it could cause changes with mentation and residents may not be able to protect themselves from a potential fall. On October 2, 2023, at 4:12 p.m., the Director of Nursing (DON) and the Administrator (ADM) were interviewed regarding Resident 1 ' s Depakote ER 500 mg at bedtime and Depakote DR 500 mg at bedtime medication duplication of orders, and interviews conducted with nurses verifying they have administered both medications on June 28, 2023, through July 11, 2023. The order produced unnecessary medication to address behavior management. A review of the facility policy titled, Medication - Verification, dated January 1, 2012, indicated, Purpose: Medications are administered safely and appropriately as ordered. Policy: I. It is the responsibility of Nursing Staff to be aware of the classification, action, correct dosage, and side effects of medication before administration. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055042 If continuation sheet Page 5 of 5